Bacterial and Fungal Infections in Persons Who Inject Drugs — Western New York, 2017

Kathleen P. Hartnett, PhD; Kelly A. Jackson, MPH; Christina Felsen, MPH; Robert McDonald, MD; Ana Cecilia Bardossy, MD; Runa H. Gokhale, MD; Ian Kracalik, PhD; Todd Lucas, MD; Olivia McGovern, PhD; Chris A. Van Beneden, MD; Michael Mendoza, MD; Michele Bohm, MPH; John T. Brooks, MD; Alice K. Asher, PhD; Shelley S. Magill, MD, PhD; Anthony Fiore, MD; Debra Blog, MD; Elizabeth M. Dufort, MD; Isaac See, MD; Ghinwa Dumyati, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(26):583-586. 

In This Article

Abstract and Introduction

Introduction

During 2014–2017, CDC Emerging Infections Program surveillance data reported that the occurrence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections associated with injection drug use doubled among persons aged 18–49 years residing in Monroe County in western New York.* Unpublished surveillance data also indicate that an increasing proportion of all Candida spp. bloodstream infections in Monroe County and invasive group A Streptococcus (GAS) infections in 15 New York counties are also occurring among persons who inject drugs. In addition, across six surveillance sites nationwide, the proportion of invasive MRSA infections that occurred in persons who inject drugs increased from 4.1% of invasive MRSA cases in 2011 to 9.2% in 2016.[1] To better understand the types and frequency of these infections and identify prevention opportunities, CDC and public health partners conducted a rapid assessment of bacterial and fungal infections among persons who inject drugs in western New York. The goals were to assess which bacterial and fungal pathogens most often cause infections in persons who inject drugs, what proportion of persons who inject use opioids, and of these, how many were offered medication-assisted treatment for opioid use disorder. Medication-assisted treatment, which includes use of medications such as buprenorphine, methadone, and naltrexone, reduces cravings and has been reported to lower the risk for overdose death and all-cause mortality in persons who use opioids.[2,3] In this assessment, nearly all persons with infections who injected drugs used opioids (97%), but half of inpatients (22 of 44) and 12 of 13 patients seen only in the emergency department (ED) were not offered medication-assisted treatment. The most commonly identified pathogen was S. aureus (80%), which is frequently found on skin. Health care visits for bacterial and fungal infections associated with injection opioid use are an opportunity to treat the underlying opioid use disorder with medication-assisted treatment. Routine care for patients who continue to inject should include advice on hand hygiene and not injecting into skin that has not been cleaned or to use any equipment contaminated by reuse, saliva, soil, or water.[4,5]

The team obtained and reviewed records for hospital admissions and ED visits during April 1–June 30, 2017, from a convenience sample of five hospitals in western New York. Patients of any age who had 1) positive cultures for S. aureus (excluding nasal specimens), Candida spp. in blood, or GAS from a normally sterile site or 2) diagnostic codes related to substance use and a bacterial or fungal pathogen or infection were included. Injection drug use was defined as patient self-report of injection drug use; health care worker, relative, or friend report that the person injected drugs; or observation of injection equipment in the patient's room or belongings or skin lesions indicative of injection drug use (track marks). Demographic information, infection sites, bacterial and fungal pathogens, history of human immunodeficiency virus (HIV), hepatitis B and C, and clinical outcomes were abstracted from medical records for all patients with injection drug use. Information on substance use history and treatment was collected for a subset of persons whose infections were identified from S. aureus, Candida spp., or GAS culture. A chi-squared test was performed using SAS (version 9.4; SAS Institute) to compare the proportion of patients seen only in the ED to the proportion of hospitalized patients who were offered medication-assisted treatment. To assess the sensitivity of identifying patients with infections using diagnostic codes alone, the proportion of patients who injected drugs identified by positive cultures who also had diagnostic codes for both substance use and a bacterial or fungal pathogen or infection was calculated.

Among 1,002 patients who met either inclusion criterion, medical records for 111 (11%) documented injection drug use during the previous 12 months. The median age of these persons was 32 years (range = 18–68 years); 61% were women (Table). Skin and soft tissue infections accounted for 82 (74%) infections, and endocarditis accounted for 16 (14%). Among skin and soft tissue infections, 50 (61%) were documented to be at an injection site, and 12 (15%) were not at an injection site. For 20 patients (24%), the medical record did not document whether the infection was at a site where the person injected drugs. Overall, 79 persons (71%) were hospitalized, of whom 19 (24%) were hospitalized for ≥30 days. Four (4%) patients died before leaving the hospital. Thirty-three (30%) patients left the hospital against medical advice, including 13 (41%) of 32 persons seen only in the ED and 20 (25%) of 79 persons admitted to the hospital.

Of 70 patients with at least one pathogen identified from a clinical culture, 13 (19%) had a polymicrobial infection. The most common bacterial and fungal pathogens were S. aureus (56; 80%); streptococci (11; 16%), including eight viridans group and two GAS; and Candida spp. (4; 6%). The most common bloodborne pathogen identified§ was hepatitis C virus; 41 (37%) patients had a current or previous hepatitis C virus infection documented in the medical record; seven (6%) had a history of HIV infection, and four (4%) had hepatitis B virus infection.

Among a subset of 59 (53%) patients with S. aureus, Candida spp., or GAS infections from whom drug use data were collected, 57 (97%) used opioids, including 50 who injected opioids and seven with an unknown route of opioid administration. Among 44 inpatients, 22 (50%) were offered medication-assisted treatment for opioid use disorder, whereas one of 13 (8%) persons seen only in the ED was offered medication-assisted treatment (p-value = 0.01). Most patients with an infection identified by culture (74%) also had diagnostic codes for both substance use and an infection or pathogen.

* https://idsa.confex.com/idsa/2018/webprogram/Paper72151.html.
Infection and substance use related codes: A18.84, A31*, A32.82, A39*, A39.51, A41*–A44*, A46*, A48*, A49*, A54.83, B37* –B46*, B49, B95*–B96*, B99.8*, B99.9*, D73.3, E06.0, E32.1, G06*, H05*, I08, I33*, I38, I39, I40.0, I51.89, 172.9, I76, I80*, I96, J85*, J86*, K11.3, K12.2, K13.0, K61*, K65*, K68.1*, L01*–L04*, L08*, L97*, L98.4*, M00*, M01*, M27.2, M46.2*, M46.3*–M46.5, M65.0*, M71.0*, M72.6, M72.8, M86*, N15.1, R65.2*, R78.81, T79.8XXA, T80.2*, Z16, Z79.2. ICD-10 substance use related codes: F11*, F13*–F16*, F18*, F19*, T40*.
§ Hepatitis B virus (HBV), hepatitis C virus (HCV), HIV chronic or acute infection noted in the medical history, or the patient had 1) positive HBV surface antigen, 2) positive HCV antibody without RNA tested (could indicate resolved or cured infection) or detectable HCV viral load, or 3) positive HIV test in the record.

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